Outcomes In Ambulatory Patients Research Articles

Synthesis and Meta-analysis of 3 Randomized Trials Conducted in Burkina Faso, Ghana, and Uganda Comparing the Effects of Point-of-Care Tests and Diagnostic Algorithms Versus Routine Care on Antibiotic Prescriptions and Clinical Outcomes in Ambulatory Patients

This meta-analysis included 3 randomized trials conducted in sub-Saharan Africa comparing the effects of point-of-care tests and diagnostic algorithms versus routine care on antibiotic prescriptions and clinical outcomes in ambulatory patients presenting at outpatient facilities with acute uncomplicated febrile illness.

GLIM in diagnosing malnutrition and predicting outcome in ambulatory patients with head and neck cancer.

This study aimed to determine the prevalence of malnutrition in a head and neck cancer (HNC) population according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and to assess its relation to survival. The secondary aim was to compare GLIM criteria to Patient-Generated Subjective Global Assessment (PG-SGA) and Nutritional Risk Screening 2002 (NRS 2002) methods. The assessment was performed in a series of 65 curative patients with newly diagnosed HNC in a nutrition intervention study. Malnutrition was defined as PG-SGA classes BC and nutritional risk as NRS 2002 score ≥3 and was retrospectively diagnosed with GLIM criteria in prospectively collected data at diagnosis. Sensitivity, specificity, and kappa (κ) were analyzed. Predictive accuracy was assessed by calculating the area under curve (AUC) b y receiver operating characteristic (ROC) analysis. Kaplan-Meier and Cox regression analyses were used to evaluate association between malnutrition and overall survival (OS), and disease-free survival (DFS). GLIM-defined malnutrition was present in 37% (24/65) of patients. The GLIM showed 77% sensitivity and 84% specificity with agreement of κ = 0.60 and accuracy of AUC = 0.80 (p < 0.001) with PG-SGA and slightly higher sensitivity (83%) with NRS 2002 (κ = 0.58). Patients with GLIM-defined malnutrition had shorter OS (56 vs. 72 months, HR 2.26, 95% CI 1.07-4.77, p = 0.034) and DFS (37 vs. 66 months, HR 2.01, 95% CI 0.99-4.09, p = 0.054), than well-nourished patients. The adjusted HR was 2.53 (95% CI 1.14-5.47, p = 0.023) for OS and 2.10 (95% CI 0.98-4.48, p = 0.056) for DFS in patients with GLIM-defined malnutrition. A substantial proportion of HNC patients were diagnosed with malnutrition according to the GLIM criteria and this showed a moderate agreement with NRS 2002- and PG-SGA-defined malnutrition. Even though the GLIM criteria had strong association with OS, its diagnostic value was poor. Therefore, the GLIM criteria seem potential for malnutrition diagnostics and outcome prediction in the HNC patient population. Furthermore, NRS 2002 score ≥3 indicates high nutritional risk in this patient group.

Which frailty tool best predicts morbidity and mortality in ambulatory patients with heart failure? A prospective study.

Frailty is common in patients with heart failure (HF) and is associated with adverse outcome, but it is uncertain how frailty should best be measured. To compare the prognostic value of commonly-used frailty tools in ambulatory patients with HF. We assessed, simultaneously, three screening tools [clinical frailty scale (CFS); Derby frailty index (DFI); acute frailty network (AFN) frailty criteria), three assessment tools (Fried criteria; Edmonton frailty score (EFS); deficit index (DI)) and three physical tests (handgrip strength, timed get-up-and-go test (TUGT), 5-metre walk test (5MWT)] in consecutive patients with HF attending a routine follow-up visit. 467 patients (67% male, median age=76 years, median NT-proBNP = 1156ng/L) were enrolled. During a median follow-up of 554 days, 82 (18%) patients died and 201 (43%) patients were either hospitalised or died. In models corrected for age, Charlson score, haemoglobin, renal function, sodium, NYHA, atrial fibrillation (AF), and body mass index, only log[NT-proBNP] and frailty were independently associated with all-cause death. A base model for predicting mortality at 1 year including NYHA, log[NT-proBNP], sodium and AF, had a C-statistic=0.75. Amongst screening tools: CFS (C-statistic=0.84); amongst assessment tools: DI (C-statistic=0.83) and amongst physical test: 5MWT (C-statistic=0.80), increased model performance most compared with base model (P<0.05 for all). Frailty is strongly associated with adverse outcomes in ambulatory patients with HF. When added to a base model for predicting mortality at 1 year including NYHA, NT-proBNP, sodium, and AF, CFS provides comparable prognostic information with assessment tools taking longer to perform.

Sex Differences in Left Ventricular Assist Device-related Emergency Department Encounters in the United States

BackgroundThere is a paucity of data regarding sex differences in the profiles and outcomes of ambulatory patients on left ventricular assist device (LVAD) support who present to the emergency department (ED). Methods and ResultsWe performed a retrospective analysis of 57,200 LVAD-related ED patient encounters from the 2010 to 2018 Nationwide Emergency Department Sample. International Classification of Diseases Clinical Modification, Ninth Revision and Tenth Revision, codes identified patients aged 18 years or older with LVADs and associated primary and comorbidity diagnoses. Clinical characteristics and outcomes were stratified by sex and compared. Multivariable logistic regression was used to evaluate predictors of hospital admission and death. Female patient encounters comprised 27.2% of ED visits and occurred at younger ages and more frequently with obesity and depression (all P < .01). There were no sex differences in presentation for device complication, stroke, infection, or heart failure (all P > .05); however, female patient encounters were more often respiratory- and genitourinary or gynecological related (both P < .01). After adjustment for age group, diabetes, depression, and hypertension, male patient encounters had a 38% increased odds of hospital admission (95% confidence interval 1.20–1.58), but there was no sex difference in the adjusted odds of death (odds ratio 1.11, 95% confidence interval 0.86–1.45). ConclusionsPatient encounters of females on LVAD support have significantly different comorbidities and outcomes compared with males. Further inquiry into these sex differences is imperative to improve long-term outcomes.

Comparison of telerehabilitation versus home-based video exercise in patients with Duchenne muscular dystrophy: a single-blind randomized study

IntroductionPatients with Duchenne muscular dystrophy (DMD) have lost their access to on-site rehabilitation due to the COVID-19 pandemic. Telerehabilitation can be a viable approach for these patients to protect their muscle strength and functional status. The aim of this study is to compare telerehabilitation with home-based video exercises.Patients and methodsMale, ambulatory DMD patients were randomized into telerehabilitation and video-exercise groups. Nineteen patients were included in the final analyses. Telerehabilitation consisted of live online exercises, while video exercise implemented a pre-recorded video as a home-based program. Both programs spanned 8 weeks, three times a week. Patients’ muscle strength with a hand-held dynamometer, Quick Motor Function Test, North-Star Ambulatory Assessment (NSAA), 6-Minute Walk Test (6MWT) and Caregiver Burden were recorded before and after treatment.ResultsThe 6MWT of the telerehabilitation group was391.26 ± 95.08 m before and387.75 ± 210.93 after treatment (p = 0.94) and 327.46 ± 103.88 m before treatment and313.77 ± 114.55 after treatment in video group (p = 0.63). The mean NSAA score of the telerehabilitation group were26.70 ± 8.04 before treatment and 25.20 ± 11.33 after treatment (p = 0.24). In the video group scores were 21.66 ± 6.65 before to 22.00 ± 8.61 after treatment (p = 0.87). There were no significant changes between groups at the end of the treatments. The telerehabilitation group's neck extension, bilateral shoulder abduction, and left shoulder flexion, bilateral knee flexion and extension, bilateral ankle dorsiflexion, and left ankle plantar flexion strength improved significantly and were better than the video group (p < 0.05 for all measurements).ConclusionA telerehabilitation approach is superior in improving muscle strength than a video-based home exercise, but none of the programs improved functional outcomes in ambulatory patients with DMD.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13760-022-01975-4.

Bamlanivimab and Etesevimab Improve Symptoms and Associated Outcomes in Ambulatory Patients at Increased Risk for Severe Coronavirus Disease 2019: Results From the Placebo-Controlled Double-Blind Phase 3 BLAZE-1 Trial.

BackgroundIn the phase 2/3 BLAZE-1 trial, bamlanivimab and etesevimab together reduced coronavirus disease 2019 (COVID-19)–related hospitalizations and any-cause mortality in ambulatory patients. Herein, we assess the impact of bamlanivimab and etesevimab treatment on the severity and length of symptoms and health outcomes among patients at increased risk for severe COVID-19.MethodsIn the phase 3 portion of BLAZE-1 (NCT04427501), symptomatic patients with increased risk for severe COVID-19 were randomized (2:1) to a single infusion of 700 mg bamlanivimab and 1400 mg etesevimab or placebo. Hospitalization events, vital signs, and symptomatology were monitored throughout the trial.ResultsOverall, 769 patients were randomized to bamlanivimab and etesevimab together (n = 511) or placebo (n = 258). The time to sustained symptom resolution was significantly shorter among patients who received bamlanivimab and etesevimab compared with placebo (8 vs 10 days; P < .01). The median time to first sustained symptom resolution of body aches and pain, chills, fatigue, feeling feverish, headache, and shortness of breath was significantly different in patients receiving bamlanivimab and etesevimab compared to placebo (P < .05). The proportion of patients who experienced COVID-19–related hospitalization by day 29 was significantly reduced among the bamlanivimab and etesevimab group compared with placebo (0.8% vs 5.4%; P < .01). The mean duration of hospital stay was numerically shorter among patients who received bamlanivimab and etesevimab (7.3 vs 13.5 days; P = .16), with fewer intensive care admissions.ConclusionsPatients receiving bamlanivimab and etesevimab together resolved their symptoms more rapidly than those receiving placebo. Bamlanivimab and etesevimab treatment was associated with reduced rates of hospitalizations and shorter hospital stays.Clinical Trials RegistrationNCT04427501.

Characteristics and outcomes of ambulatory patients with suspected COVID-19 at a respiratory referral center

RationaleSARS-CoV-2 continues to cause a global pandemic and management of COVID-19 in outpatient settings remains challenging. Objective: We sought to describe characteristics of patients with chronic respiratory disease (CRD) experiencing symptoms consistent with COVID-19, who were seen in a novel Acute Respiratory Clinic, prior to widely available testing, emergence of variants, COVID-19 vaccination, and post-vaccination (breakthrough) SARS-CoV-2 infections. Methods: Retrospective electronic medical record data were analyzed from 907 adults with presumed COVID-19 seen between March 16, 2020 and January 7, 2021. Data included demographics, comorbidities, medications, vital signs, laboratory tests, pulmonary function tests, patient disposition, and co-infections. The overdispersed data (aod) R package was used to create a logit model using COVID-19 diagnosis by PCR as the dichotomous outcome variable. Univariate, conventional multivariate and elastic net machine learning were used to analyze data. Results: Male gender, elevated baseline temperature, and respiratory rate predicted COVID-19 diagnosis. Eosinopenia, neutrophilia, and lymphocytosis were also associated with COVID-19 diagnosis. However, asthma and COPD diagnoses were not associated with SARS-CoV-2 PCR positive test. Male gender, low oxygen saturation, and lower forced expiratory volume in 1 s (FEV1) were associated with higher hospital referral. Conclusions: CRD patients with acute respiratory symptoms in the ambulatory setting were more likely to have COVID-19 if male, febrile and tachypneic. Patients with lower pre-morbid FEV1 and lower SPO2 are more likely to be referred to the hospital. A composite of vitals sigs and WBC differential help risk stratify CRD patients seeking care for presumed COVID-19.

Circulatory Power is Superior to Peak Oxygen Consumption in Predicting Adverse Outcomes in Ambulatory Patients Assessed for Heart Transplantation

<h3>Purpose</h3> To assess the utility of circulatory power (CP) (peak systolic blood pressure • peak oxygen consumption [VO2]) to stratify risk and predict adverse outcomes in outpatients with advanced heart failure (HF). <h3>Methods</h3> Between March 2017 and April 2021, 264 outpatients with advanced HF had cardiopulmonary exercise testing (CPET), 6-minute walk test, right heart catheterisation and standard blood panel to assess severity of HF and suitability for heart transplantation (HTx) or mechanical circulatory support (MCS). The primary end point was a composite of urgent HTx, MCS or death. Clinical, laboratory and CPET parameters were evaluated as predictors of adverse outcomes using univariate and multivariate Cox and Fine-Gray regression. <h3>Results</h3> Over a median follow up of 1.4 years, 86 patients (32.6%) experienced an adverse outcome (29 urgent HTx, 26 MCS, 31 deaths). CP and NT-proBNP levels were the only significant predictors of primary end point on multivariate analysis (Table). Amongst patients with peak VO2 ≥ 12 ml/min/kg (≥ 14 ml/min/kg if beta-blocker intolerant), those with lower CP values had a higher incidence of adverse outcomes (p=0.004) (Figure). <h3>Conclusion</h3> In our cohort of outpatients with advanced HF, CP and NT-proBNP were the strongest predictors of the composite end point of urgent HTx, MCS or death. CP offered incremental prognostic information above guideline recommended thresholds for peak VO2. Further research to assess the role of CP to help guide decisions regarding optimal timing for HTx listing is warranted.

A Randomized, Placebo-Controlled Clinical Trial of Bamlanivimab and Etesevimab Together in High-Risk Ambulatory Patients With COVID-19 and Validation of the Prognostic Value of Persistently High Viral Load.

BackgroundBased on interim analyses and modeling data, lower doses of bamlanivimab and etesevimab together (700/1400 mg) were investigated to determine optimal dose and expand availability of treatment.MethodsThis Phase 3 portion of the BLAZE-1 trial characterized the effect of bamlanivimab with etesevimab on overall patient clinical status and virologic outcomes in ambulatory patients ≥12 years old, with mild-to-moderate coronavirus disease 2019 (COVID-19), and ≥1 risk factor for progressing to severe COVID-19 and/or hospitalization. Bamlanivimab and etesevimab together (700/1400 mg) or placebo were infused intravenously within 3 days of patients’ first positive COVID-19 test.ResultsIn total, 769 patients were infused (median age [range]; 56.0 years [12, 93], 30.3% of patients ≥65 years of age and median duration of symptoms; 4 days). By day 29, 4/511 patients (0.8%) in the antibody treatment group had a COVID-19-related hospitalization or any-cause death, as compared with 15/258 patients (5.8%) in the placebo group (Δ[95% confidence interval {CI}] = −5.0 [−8.0, −2.1], P < .001). No deaths occurred in the bamlanivimab and etesevimab group compared with 4 deaths (all COVID-19-related) in the placebo group. Patients receiving antibody treatment had a greater mean reduction in viral load from baseline to Day 7 (Δ[95% CI] = −0.99 [−1.33, −.66], P < .0001) compared with those receiving placebo. Persistently high viral load at Day 7 correlated with COVID-19-related hospitalization or any-cause death by Day 29 in all BLAZE-1 cohorts investigated.ConclusionsThese data support the use of bamlanivimab and etesevimab (700/1400 mg) for ambulatory patients at high risk for severe COVID-19. Evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants will require continued monitoring to determine the applicability of this treatment.Clinical Trials RegistrationNCT04427501.

Liver stiffness as measured by transient elastography is a predictor of outcomes in patients with chronic heart failure with reduced, mid-range, and recovered left-ventricular ejection fraction

BackgroundTransient elastography is a noninvasive method for assessing liver stiffness (LS), which can reflect right-sided filling pressure associated with passive liver congestion in patients with HF. MethodsA prospective, single-center observational study in which LS was measured in consecutive ambulatory patients with heart failure with reduced, mid-range, and recovered left ventricular ejection fraction, between March 2018 and June 2019. Mean follow up was 219 ± 86 days. The primary endpoint was time to first event, which was defined as a composite of cardiovascular death or HF hospitalization. ResultsEighty-five patients were included in the final analysis. Mean age was 62 ± 10 and 68% were male. Mean ejection fraction and median NT-proBNP were, respectively, 38.7 ± 14.3% and 1140 pg/mL (interquartile range 224.3–2810.3). The median LS for the entire population was 6.3 (2.5-41.2) kPa. LS correlated with NT-proBNP (r = 0.46; p < 0.0001), total bilirubin (r = 0.47; p < 0.001), direct bilirubin (r = 0.43; p = 0.0001), gama-glutamyl-transpeptidase (r = 0.54; p < 0.0001), and alkaline phosphatase (r = 0.39; p = 0.0004). A Receiver Operating Characteristic (ROC) curve was performed and a cut point of 5.9 kPa showed sensitivity of 80% and specificity of 64.1% with area under the curve of 0.73. Using Cox proportional hazard model (independent variables: LS as a continuous variable, age, gender, NT-proBNP, LVEF, and creatinine), only LS was independently associated with the primary endpoint (hazard ratio 1.05, 95% confidence interval 1.01-1.09; for each increment of one unit of LS). ConclusionLS correlates with biomarkers of myocardial stretch and several liver function tests and is an independent predictor of outcomes in ambulatory patients with HF.

Functional Status and Adverse Outcomes in Ambulatory Patients Undergoing Above-Knee Versus Below-Knee Amputation in the Vascular Quality Initiative

Previous studies in the literature have demonstrated higher morbidity and mortality in patients undergoing above-knee (AKA) vs below-knee (BKA) amputations. However, very few studies have looked at the functional status between these two groups. Using a large national database, we hypothesize that patients undergoing BKA will be more likely to ambulate and have superior outcomes compared with AKA.

Effect of Monoclonal Antibody Treatment on Clinical Outcomes in Ambulatory Patients With Coronavirus Disease 2019.

We compared rates of emergency department visits or hospitalizations among ambulatory coronavirus disease 2019 (COVID-19) patients treated with monoclonal antibody (mAb) therapy (n = 305) vs untreated patients (n = 6354). Treatment was associated with decreased encounters within 30 days (adjusted odds ratio, 0.23 [95% confidence interval, .15–.36]). Our findings support treatment of acute COVID-19 with mAbs.

Pharmacist‐led optimization of heart failure medications: A systematic review

AbstractMedications are a cornerstone of treatment of heart failure (HF) with reduced ejection fraction, thus pharmacists are valuable members of the multidisciplinary team approach to long‐term patient management. As pharmacists' scope of practice has expanded, growing evidence shows an evolution in pharmacists' roles in the care of patients with HF. To synthesize the literature describing implementation of pharmacist‐led medication titration and clinical assessments on outcomes in ambulatory patients with HF. MEDLINE, Embase, and Cochrane Controlled Register of Trials were searched from 2007 to March 18, 2020. English language articles that evaluated implementation of pharmacist‐led medication titration in ambulatory patients with HF. Studies with interventions that involved pharmacists prescribing to initiate, modify, or discontinue medications with independent authority or under a collaborative practice agreement were considered. Ten retrospective studies from 718 identified articles were included. All studies incorporated pharmacist‐led guideline‐directed medical therapy (GDMT) titration, two with independent pharmacist prescribing in a multidisciplinary HF clinic, and seven in a pharmacist‐only clinic. Patients were referred from both inpatient and outpatient settings and had an average reported range of 1–5.7 visits with pharmacists. While four studies exclusively included patients with HF and ejection fraction below 45%, the mean ejection fraction of all included patients ranged from 20% to 42%. Four studies showed an increased proportion of patients on GDMT or target doses after pharmacist prescribing. Four out of six studies showed a significant decrease in all‐cause hospitalizations and one of two studies reported a significant decrease in all‐cause mortality rate with intervention. This study found that pharmacist‐led medication optimization increased the use of GDMT in ambulatory patients with HF, and may be associated with fewer hospitalizations and deaths. Future randomized controlled trials should evaluate the impact of adding pharmacist‐led HF medication optimization to standard of care on clinical outcomes.

Characteristics and Outcomes of Ambulatory Patients with Suspected COVID-19 at a Respiratory Referral Center

Characteristics and Outcomes of Ambulatory Patients with Suspected COVID-19 at a Respiratory Referral Center

MAGGIC-Predicted Mortality of >20% at One Year is Associated with Poor Prognosis in Ambulatory Patients with Advanced Heart Failure

The MAGGIC score might help select patients who would gain prognostic benefit from heart transplantation or mechanical circulatory support (MCS). We examined the association between MAGGIC predicted prognosis and actual outcomes, in order to assess predictive performance of the score and determine a threshold for identifying patients at risk. We included 702 consecutive outpatients who were assessed for heart transplantation over ten years. The MAGGIC score was calculated for each patient according to the scoring matrix and patients were stratified into quartiles. The co-primary endpoints were death, urgent heart transplantation or need for MCS. Follow up was censored at routine heart transplantation. Kaplan-Meier curves were constructed and calibration testing was performed. 320 (45.6%) patients reached a primary endpoint during a median follow-up of 547 days. MAGGIC-predicted mortality was associated with event-free survival (figure, log rank P<0.0001). The MAGGIC score was well-calibrated at one year but over-estimated event-free survival at three years. 92 (13.1%) of patients had a MAGGIC-predicted one year mortality of >20% and these patients had the worst outcomes. At this threshold, the MAGGIC score had high specificity (93.5%) but low sensitivity (20.9%), giving a positive likelihood ratio of 3.22 for death, urgent heart transplantation or the need for MCS. MAGGIC-predicted mortality is associated with real world outcomes in ambulatory patients with advanced heart failure. Clinicians should not be reassured by low MAGGIC-predicted mortality because sensitivity is poor and event-free survival at three years is lower than predicted. However, high MAGGIC-predicted mortality (>20% at one year) is a specific marker of very poor outcomes and may be used to select patients who might derive prognostic benefit from surgical treatment of advanced heart failure, such as implantation of a left ventricular assist device.

Low Pulmonary Artery Pulsatility Index Is Associated With Adverse Outcomes in Ambulatory Patients With Advanced Heart Failure

BackgroundThe pulmonary artery pulsatility index (PAPi) is a composite measure of right heart function, and low PAPi is associated with increased likelihood of mortality in patients hospitalized with cardiogenic shock. Our aim was to determine how PAPi correlates with other measures of right heart function and whether PAPi is associated with outcomes in ambulatory outpatients with advanced heart failure. MethodsWe assessed 673 consecutive ambulatory outpatients for heart transplantation over 10 years. The median age was 52 years, 72% were male, and dilated cardiomyopathy was the most common cause. All patients underwent detailed assessment, including right heart catheterization, and PAPi was calculated. The coprimary endpoints were death, urgent heart transplantation and mechanical circulatory support. ResultsMedian PAPi was 2.2 (interquartile range 1.42–3.62), and variation was predominantly due to variation in right atrial pressure. PAPi was well correlated with the right atrial pressure to pulmonary capillary wedge pressure ratio (rho –0.766) but less well correlated with the right ventricular stroke work index (rho 0.561) and tricuspid annular plane systolic excursion (rho 0.292). Patients in the lowest PAPi quartile (0.16–1.41) had lower event-free survival at 1 year (68.7%) and 3 years (45.6%) compared with all other PAPi quartiles (log rank P = 0.0286). ConclusionsPAPi offers a composite measure of right heart function that differs from other right heart catheter or echocardiographic measures. A PAPi of less than 1.41 is associated with adverse clinical outcomes in ambulatory outpatients with advanced heart failure.

Digoxin Discontinuation and Outcomes in Patients With Heart Failure With Reduced Ejection Fraction

BackgroundThe deleterious effects of discontinuation of digoxin on outcomes in ambulatory patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) receiving angiotensin-converting enzyme inhibitors are well-documented. ObjectivesThe authors sought to determine the relationship between digoxin discontinuation and outcomes in hospitalized patients with HFrEF receiving more contemporary guideline-directed medical therapies including beta-blockers and mineralocorticoid receptor antagonists. MethodsOf the 11,900 hospitalized patients with HFrEF (EF ≤45%) in the Medicare-linked OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) registry, 3,499 received pre-admission digoxin, which was discontinued in 721 patients. Using propensity scores for digoxin discontinuation, estimated for each of the 3,499 patients, a matched cohort of 698 pairs of patients, balanced on 50 baseline characteristics (mean age 76 years; mean EF 28%; 41% women; 13% African American; 65% on beta-blockers) was assembled. ResultsFour-year post-discharge, digoxin discontinuation was associated with significantly higher risks of HF readmission (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.05 to 1.39; p = 0.007), all-cause readmission (HR: 1.16; 95% CI: 1.04 to 1.31; p = 0.010), and the combined endpoint of HF readmission or all-cause mortality (HR: 1.20; 95% CI: 1.07 to 1.34; p = 0.002), but not all-cause mortality (HR: 1.09; 95% CI: 0.97 to 1.24; p = 0.163). Discontinuation of digoxin was associated with a significantly higher risk of all 4 outcomes at 6 months and 1 year post-discharge. At 30 days, digoxin discontinuation was associated with higher risks of all-cause mortality (HR: 1.80; 95% CI: 1.26 to 2.57; p = 0.001) and the combined endpoint (HR: 1.36; 95% CI: 1.09 to 1.71; p = 0.007), but not of HF readmission (HR: 1.19; 95% CI: 0.90 to 1.59; p = 0.226) or all-cause readmission (HR: 1.03; 95% CI: 0.84 to 1.26; p = 0.778). ConclusionsAmong hospitalized older patients with HFrEF on more contemporary guideline-directed medical therapies, discontinuation of pre-admission digoxin therapy was associated with poor outcomes.

Prior Heart Failure Hospitalization and Outcomes in Patients with Heart Failure with Preserved and Reduced Ejection Fraction

BackgroundA prior hospitalization resulting from heart failure is associated with poor outcomes in ambulatory patients with heart failure. Less is known about this association in hospitalized patients with heart failure and whether it varies by ejection fraction. MethodsOf the 25,345 hospitalized patients in the Medicare-linked OPTIMIZE-HF registry, 22,491 had known heart failure, of whom 7648 and 9558 had heart failure with preserved (≥50%) and reduced (≤40%) ejection fraction (HFpEF and HFrEF), respectively. Overall, 927 and 1862 patients with HFpEF and HFrEF had hospitalizations for heart failure during the 6 months before the index hospitalization, respectively. Using propensity scores for prior heart failure hospitalization, we assembled two matched cohorts of 924 pairs and 1844 pairs of patients with HFpEF and HFrEF, respectively, each balanced for 58 baseline characteristics. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes during 6 years of follow-up. ResultsAmong 1848 matched patients with HFpEF, HRs (95% CIs) for all-cause mortality, all-cause readmission, and heart failure readmission were 1.35 (1.21-1.50; P <0.001), 1.34 (1.21-1.47; P <0.001), and 1.90 (1.67-2.16; P <0.001), respectively. Respective HRs (95% CIs) in 3688 matched patients with HFrEF were 1.17 (1.09-1.26; P <0.001), 1.32 (1.23-1.41; P <0.001), and 1.48 (1.37-1.61; P <0.001). ConclusionsAmong hospitalized patients with heart failure, a previous hospitalization for heart failure is associated with higher risks of mortality and readmission in both HFpEF and HFrEF. The relative risks of death and heart failure readmission appear to be higher in HFpEF than in HFrEF.

IMPACT OF HEALTH LITERACY ON KNOWLEDGE, SELF-CARE AND CLINICAL OUTCOMES IN HEART FAILURE PATIENTS

The purpose of this study was to identify the prevalence of low health literacy (HL) and to determine whether low HL contributes to poorer disease knowledge, self-care, and clinical outcomes in ambulatory patients with heart failure (HF). We enrolled 147 English-speaking patients from our ambulatory HF clinics between January 2015 and February 2016. HL was measured with the Newest Vital Sign, knowledge with the English-version Dutch Heart Failure Knowledge Scale, and self-care with the Self-Care Heart Failure Index. Information on mortality, hospitalizations, heart transplant (HT) or left ventricular assist device (LVAD) implant were collected over two years. Primary analysis was multivariable linear or univariable logistic regression. Level of significance for all tests was pre-set at 0.05. The sample was predominantly male (73.1%) with an average age of 56.8 ± 14 years. 44 (30.3%) had low HL. Patients with low HL were significantly older (56.8 vs 54.4 years) had less formal education (47.7% vs 75.2% post-secondary), and spoke English as a second language (40.9% vs 15.8%). Patients with low HL had lower HF knowledge scores (10.8 vs 12.5). There were no significant associations between HL and self-care scores. At 18 months the risk of death, HT or LVAD was 3% for patients with adequate HL versus 24% for low HL (OR 0.28; 95% CI: 0.10-0.78, p<0.05). This study found that 30% of patients with HF have low HL. Low HL is characterized by increased age, less formal education, and English as a second language. Patients with low HL had worse outcomes at 18 months despite no difference in self-reported self-care measures.

Comorbidities, Fragility, and Quality of Life in Heart Failure Patients With Midrange Ejection Fraction

ObjectiveTo assess the effects of comorbidities, fragility, and quality of life (QOL) on long-term prognosis in ambulatory patients with heart failure (HF) with midrange left ventricular ejection fraction (HFmrEF), an unexplored area.Patients and MethodsConsecutive patients prospectively evaluated at an HF clinic between August 1, 2001, and December 31, 2015, were retrospectively analyzed on the basis of left ventricular ejection fraction category. We compared patients with HFmrEF (n=185) to those with reduced (HFrEF; n=1058) and preserved (HFpEF; n=162) ejection fraction. Fragility was defined as 1 or more abnormal evaluations on 4 standardized geriatric scales (Barthel Index, Older Americans Resources and Services scale, Pfeiffer Test, and abbreviated-Geriatric Depression Scale). The QOL was assessed with the Minnesota Living with Heart Failure Questionnaire. A comorbidity score (0-7) was constructed. All-cause death, HF-related hospitalization, and the composite end point of both were assessed.ResultsComorbidities and QOL scores were similar in HFmrEF (2.41±1.5 and 30.1±18.3, respectively) and HFrEF (2.30±1.4 and 30.8±18.5, respectively) and were higher in HFpEF (3.02±1.5, P<.001, and 36.5±20.7, P=.003, respectively). No statistically significant differences in fragility between HFmrEF (48.6%) and HFrEF (41.9%) (P=.09) nor HFpEF (54.3%) (P=.29) were found. In univariate analysis, the association of comorbidities, QOL, and fragility with the 3 end points was higher for HFmrEF than for HFrEF and HFpEF. In multivariate analysis, comorbidities were independently associated with the 3 end points (P≤.001), and fragility was independently associated with all-cause death and the composite end point (P<.001) in HFmrEF.ConclusionComorbidities and fragility are independent predictors of outcomes in ambulatory patients with HFmrHF and should be considered in the routine clinical assessment of HFmrEF.